Acute Pain Management in Opioid-tolerant Individuals

Testing Interventions to Address Bias About Patients with Opioid Use Disorder in the Emergency Department

INTRODUCTION

Reducing nurse bias about patients with opioid use disorder in the emergency department is critical for providing nonjudgmental care, enhancing patient outcomes, supporting effective communication, and promoting a holistic approach to care. Emergency nurses can make a positive impact on the lives of individuals diagnosed as having opioid use disorder by providing care that is free from stigma and discrimination.

METHODS

The study used an observational, pretest-posttest design to compare educational sessions addressing bias and stigma toward patients with opioid use disorder. The study population consisted of emergency nurses who self-selected into a virtual learning experience consisting of e-modules or simulation-based experience consisting of simulation-based experience consisting of simulation, discussion, and a speaker.

RESULTS

After the intervention, the simulation-based experience group showed an increase in total score postintervention from a mean of 118.6 to a mean of 127.1 (P < .001). The virtual learning experience group also showed an increase in total score postintervention from a mean of 116.3 to 120.7 (P < .001). Although both groups showed an increase in scores over time, the simulation-based experience group had a greater increase (P = .0037). Within the simulation-based experience, there was an increase in scores across all age groups (P < .05) but a significantly greater increase in scores among younger nurses (18-29 years) than the older age groups (P = .006).

DISCUSSION

Opioid use disorder is a complex condition that requires a comprehensive and holistic approach to care. Study results indicate that providing an educational experience to address stigma about patients diagnosed as having opioid use disorder can significantly affect nurse perceptions about these patients and their self-efficacy when working with them. However, investing in a simulation-based educational experience provides a stronger experience and results in greater change, particularly for younger, less experienced emergency nurses.

Multimodal analgesia is superior to opiates alone after tibial fracture in patients with substance abuse history

Objectives: To evaluate the effectiveness of multimodal analgesia in patients with a tibial shaft fracture. Design: Retrospective review. Setting: Large, urban, academic center. Patients: One hundred thirty-eight patients were evaluated before implementation of multimodal analgesia. Thirty-four patients were evaluated after implementation. All patients were treated operatively with internal fixation for their tibial shaft fracture. Patients with polytrauma were excluded. Intervention: Multimodal analgesia. Main Outcome Measures: Pain levels at rest and with movement were assessed. Morphine milligram equivalents (MMEs) dosed per patient were calculated each day. Length of stay was also documented. Results: After implementation of a multimodal analgesic program, there was a statistically significant decrease in pain score at rest (4.7-4.0, P = 0.034) and with movement (5.8-4.8, P = 0.007). MMEs dosed in the multimodal analgesic program correlated with pain score (R² = 0.5), whereas before implementation of the program, MMEs dosed were not dependent on pain score (R² = 0.007). Patients with a history of substance abuse had the most profound effect from this paradigm change. For those with a history of substance abuse, treatment of pain using a multimodal approach reduces MMEs dosed and length of stay (5.7-3.1 days, P = 0.016). Conclusions: Multimodal analgesia improves patient pain scores both at rest and during movement. In patients with a history of substance abuse, multimodal analgesia not only decreases pain but also decreases length of stay and MMEs dosed to levels consistent with someone who does not have a substance abuse history. Level of Evidence: Therapeutic Level III.

Role of VVZ-149, a Novel Analgesic Molecule, in the Affective Component of Pain: Results from an Exploratory Proof-of-Concept Study of Postoperative Pain following Laparoscopic and Robotic-Laparoscopic Gastrectomy

OBJECTIVE

VVZ-149 is a small molecule that both inhibits the glycine transporter type 2 and the serotonin receptor 5 hydroxytryptamine 2 A. In a randomized, parallel-group, and double-blind trial (NCT02844725), we investigated the analgesic efficacy and safety of VVZ-149 Injections, which is under clinical development as a single-use injectable product for treating moderate to severe postoperative pain.

METHODS

Sixty patients undergoing laparoscopic and robotic-laparoscopic gastrectomy were randomly assigned to receive a 10-hour intravenous infusion of VVZ-149 Injections or placebo, initiated approximately 1 hour before completion of surgical suturing. Major outcomes included pain intensity and opioid consumption via patient-controlled analgesia and rescue analgesia provided "as needed." The treatment efficacy of VVZ-149 was further examined in a subpopulation requiring early rescue medication, previously associated with the presence of high levels of preoperative negative affect in a prior Phase 2 study (NCT02489526).

RESULTS

Pain intensity was lower in the VVZ-149 (n = 30) than the placebo group (n = 29), reaching statistical significance at 4 hours post-emergence (P < .05), with a 29.5% reduction in opioid consumption for 24 hours and fewer demands for patient-controlled analgesia. In the rescued subgroup, VVZ-149 further reduced pain intensity (P < .05) with 32.6% less opioid consumption for 24 hours compared to placebo patients.

CONCLUSIONS

VVZ-149 demonstrated effective analgesia with reduced postoperative pain and opioid requirements. Consistent with the results from the previous Phase 2 study, patients with early rescue requirement had greater benefit from VVZ-149, supporting the hypothesis that VVZ-149 may alleviate the affective component of pain and mitigate excessive use of opioids postoperatively.

A national survey of approaches to manage the ICU patient with opioid use disorder

PURPOSE

Opioid associated admissions to the Intensive Care Unit (ICU) are increasing, but how institutions manage the care of these patients is unknown. We studied the availability of protocols and guidelines in Intensive Care Units (ICUs) for the management of the critically ill patient with opioid use disorder.

MATERIALS AND METHODS

A survey was sent to a random sampling of ICU clinicians at acute care hospitals in the United States.

RESULTS

Of the 300 hospitals contacted, 118 agreed to participate and 58 submitted surveys (49%, 58/118 response rate). While a majority of ICUs has a guideline to titrate sedative analgesics, only 7% reported a guideline that addresses the sedation needs of patients with opioid use disorder. Only one respondent identified a guideline for the continuation of medication-assisted treatment such as methadone. Most respondents did not have, or were unaware of, a guideline to manage opioid withdrawal or to prevent over-reversal with naloxone. Outpatient resources were offered to patients by 36% of institutions, while even fewer reported the use of a dedicated addiction care team.

CONCLUSIONS

Few institutional guidelines exist to provide clinicians with the tools necessary to prevent harm and promote recovery for this growing and vulnerable ICU population.

Comprehensive Perioperative Management Considerations in Patients Taking Methadone

PURPOSE OF REVIEW

Well-informed staff can help decrease risks and common misconceptions regarding opioid-tolerant patients, especially those taking methadone.

RECENT FINDINGS

In 2015, opioid pain relievers were the second most used drug at 3.8 million. Overdose death was three times greater in 2015 than in 2000. Medication-assisted treatment was sought by more than 2 million individuals with substance use disorder, one of which is methadone. Chronic pain affects millions of adults in the USA. Opioid therapy is widely used among these adults. Related to the risk of abuse and dependence, guidelines suggest that opioid therapy may not be considered first-line treatment. A multidisciplinary approach, including thorough preoperative evaluation, the utilization of multimodal pain management strategies, and opioid-sparing techniques in both the intraoperative and postoperative periods will allow for the best possible outcome.

Multimodal Pain Management for Major Joint Replacement Surgery

Effective pain management for orthopaedic major joint replacement is key to achieving earlier recovery, better functioning, and high rates of patient satisfaction. In an effort to decrease opioid dependency, practitioners are turning to multimodal pain management, which involves the use of multiple analgesic agents and techniques. To utilize this technique, a patient's history of and preoperative consumption of medications to treat pain impacts the success of this regimen. Multimodal pain management involves the use of nonsteroidal anti-inflammatory drugs, acetaminophen, N-methyl-D-aspartate antagonists, gabapentin, serotonin inhibitors, regional techniques, and opioids as needed. It is necessary for the nurse to understand the mechanism of pain and how the multimodal adjuncts target the pain response to benefit the patient's perioperative course as well as his or her postoperative and discharge management.